Provider First Line Business Practice Location Address:
109 W WATAUGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-232-2600
Provider Business Practice Location Address Fax Number:
423-467-3644
Provider Enumeration Date:
05/15/2012